Other·October 24, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of two linked complaints. Complaint numbers: CA00643342 and CA00646247 Representing the California Department of Public Health: Surveyor 37569/3134, HFEN The inspection was limited to the specific linked complaints investigated and does not reflect the findings of a full inspection of the facility. The allegation was substantiated with violations of the regulations, and two deficiencies were issued for linked complaints CA00643342 and CA00646247.

F622 SS=D Transfer and Discharge Requirements CFR(s): 483.15(c)(1)(i)(ii)(2)(i)-(iii)

F622 08/08/2019 §483.15(c) Transfer and discharge§483.15(c)(1) Facility requirements(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c) (1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement its transfer/discharge policy, consult the physician for discharge planning, and provide a written discharge summary for one of three residents (Resident A) who was transferred to the hospital and refused readmission to the facility. This failure increased the potential for harm for Resident A and caused emotional distress for Resident A's family. Findings: On June 27, 2019, Resident A's family member (FM) 1 was interviewed by telephone. FM 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated Resident A had a brain injury seven years ago and had been a resident at the facility for the past six years. FM 1 stated Resident A was wheelchair bound and required multiple medications. FM 1 stated the facility sent Resident A to (name of hospital) HOSP 1 on June 17, 2019, for a psychiatric evaluation, and Resident A was supposed to stay at HOSP 1 for a few days to adjust his medications. FM 1 stated Resident A's medications were changed, Resident A's condition improved, and when the doctor at HOSP 1 called the facility to have Resident A re-admitted to the facility, the facility would not accept Resident A back. On June 28, 2019, at 10:16 a.m., Resident A's record was reviewed and indicated Resident A, a young adult, was admitted to the facility on July 19, 2013, with diagnoses that included traumatic brain injury and history of seizures. The record indicated Resident A required extensive 1-2 person assistance for his activities of daily living, was wheelchair bound, and had a BIMS score of 12 (Brief Interview Mental Status-standardized assessment used to determine cognitive ability with score of 0 lowest and 15 highest). The History and Physical, dated August 30, 2018, indicated Resident A did not have the capacity to make decisions. The physician's order dated June 13, 2019, at 10:18 p.m., indicated, "May send resident (Resident A) out for Psychiatric evaluation one time only for 1 week". The "Physician's Progress Notes" indicated Resident was last seen by his physician on May 24, 2019, and facility Psychiatrist on May 20, 2019. There was no documented indication Resident A's attending physician or facility Psychiatrist were informed of Resident A's condition or medication changes, or spoke to HOSP 1 when HOSP 1 requested to discharge Resident A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE back to the facility. There was no dcoumented indication of a discharge or written discharge summary for Resident A. On June 28, 2019, at 11 a.m., the Case Manager (CM) was interviewed and stated Resident A had been at the facility for years, his family lived close by and visited Resident A almost daily. The CM stated the goals when Resident A was sent to HOSP 1 were to get Resident A evaluated by the hospital's Psychiatrist and then get Resident A transferred to an acute rehabilitation facility. The CM stated Resident A needed a three day qualifying stay at the hospital in order to be transferred to another long-term care facility. The CM stated Resident A's behaviors at the facility were escalating. HOSP 1 had more options for Resident A, and was better able to find another facility for Resident A to go to. The CM stated he spoke to HOSP 1's Case Manager and HOSP 1 expected Resident A to stay in the hospital about 7-10 days to adjust his medications. The CM stated he reviewed the changes HOSP 1 made to Resident A's medications and did not talk to Resident A's facility Psychiatrist about his condition or medications when HOSP 1 wanted to discharge Resident A. The CM stated the facility's Administrator (ADMIN), Director of Nursing (DON), and department supervisors met and decided the facility would not readmit Resident A due to his past behaviors. On June 28, 2019, at 11:50 a.m., the DON was interviewed and stated the facility thought Resident A's medications were not working and his behaviors were escalating before Resident A was transferred to HOSP 1. The DON stated she got a call form a nurse at HOSP 1 on June 21, 2019, that Resident A was ready to be discharged back to the facility, and the DON told the nurse the facility would not re-admit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A. On June 28, 2019, at 1:45 p.m., the DON was further interviewed and stated Resident A's facility physician was informed on June 27, 2019, that Resident A was not coming back to the facility and the physician did not participate in the facility's decision. On July 12, 2019, at 12:55 p.m., the DON was interviewed by telephone and stated Resident A was not at the facility, and an appeals hearing regarding the facility's refusal to readmit Resident A was held the previous week. On July 19, 2019, the document titled, "...Office of Administrative Hearings and Appeals...Refusal to Readmit: (name of Resident A)...Decision and Order..." dated July 15, 2019, was reviewed and indicated, "...On June 21, 2019 (name of facility) advised (name of HOSP 1) ...that it would not re-admit (name of Resident A)...following his transfer to (HOSP 1)...On June 27, 2019, (name of FM 1)...requested an appeal hearing to assert Resident's right to readmission...Conclusions...Facility's actions are tantamount to an involuntary discharge...A SNF (Skilled Nursing Facility) may not use hospitalization as a mechanism to transact the permanent discharge of a resident...Facility failed to provide Resident with the due process that is required at a time SNF determines that a resident cannot be readmitted...which include...issuing a written notice; providing sufficient preparation for discharge; and completing a post-discharge plan of care..." The facility policy and procedure titled, "Transfer/Discharge Documentation" last revised November 21, 2017, was reviewed and indicated, "...The facility will...Develop and implement an effective discharge planning FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE process...When the facility anticipates a discharge, a resident must have a discharge summary...comprehensive care plan must identify the care or service being declined, the risk...to the resident, and...efforts...to...educate the resident and representative...basis for the transfer of (sic) discharge...will be documented by the physician...When the Transfer of Discharge is Facility Initiated while the resident is still hospitalized...the medical record shall show evidence that the facility made efforts to...Determine if the resident still requires the services of the facility...Ascertain an accurate status of the resident's condition...Work with the hospital to ensure the resident's condition and needs are within the...scope of care, prior to hospital discharge..."

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 08/08/2019 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident A) to the facility after hospitalization. This failure increased the potential for emotional distress to Resident A, and his family. Findings: On June 27, 2019, Resident A's family member (FM) 1 was interviewed by telephone. FM 1 stated Resident A had a brain injury seven years ago and had been a resident at the facility for the past six years. FM 1 stated Resident A was wheelchair bound and required multiple medications. FM 1 stated the facility sent Resident A to (name of hospital) HOSP 1 on June 17, 2019, for a psychiatric evaluation, and Resident A was supposed to stay at HOSP 1 for a few days to adjust his medications. FM 1 stated Resident A's medications were changed, Resident A's condition improved, and when the doctor at HOSP 1 called the facility to have Resident A discharged, the facility told HOSP 1 they would not readmit Resident A to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility. On June 28, 2019, at 9:40 a.m., an unannounced visit was made to the facility for the investigation of two linked complaints. On June 28, 2019, at 10:16 a.m., Resident A's record was reviewed and indicated Resident A, a young adult, was admitted to the facility on July 19, 2013, with diagnoses that included traumatic brain injury and history of seizures. The record indicated Resident A required extensive 1-2 person assistance for his activities of daily living, was wheelchair bound, and had a BIMS score of 12 (Brief Interview Mental Status-standardized assessment used to determine cognitive ability with score of 0 lowest and 15 highest). The History and Physical, dated August 30, 2018, indicated Resident A did not have the capacity to make decisions. The physician's order dated June 13, 2019, at 10:18 p.m., indicated, "May send resident (Resident A) out for Psychiatric evaluation one time only for 1 week". The "Physician's Progress Notes" indicated Resident was last seen by his physician on May 24, 2019, and the facility's psychiatrist on May 20, 2019. There was no documented indication Resident A's attending physician or Psychiatrist were informed of Resident A's condition or medication changes, or spoke to HOSP 1 when HOSP 1 requested to discharge Resident A back to the facility. The form titled, "Transfer Bed-Hold Notification Policy" dated June 18, 2019, indicated Resident A was transferred to HOSP 1 on June 17, 2019, and FM 1 requested a bed-hold for Resident A, "...Please hold a bed vacant on any occasion during which the resident (named above) is transferred to an acute hospital and is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE expected to return within seven (7) days..." and "...Notification was made to (name of FM 1)...on...06/18/2019 regarding transfer of resident and right to a seven (7) day bedhold...Yes, I desire the bed-hold..." On June 28, 2019, at 11 a.m., the Case Manager (CM) was interviewed and stated Resident A had been at the facility for years, his family lived close by and visited Resident A almost daily. The CM stated the goals when Resident A was sent to HOSP 1 were to get Resident A evaluated by the hospital's Psychiatrist and then get Resident A transferred to an acute rehabilitation facility. The CM stated Resident A needed a three day qualifying stay at the hospital in order to be transferred to another long-term care facility. The CM stated Resident A's behaviors at the facility were escalating, HOSP 1 had more options for Resident A, and was better able to find another facility for Resident A to go to. The CM stated he spoke to HOSP 1's Case Manager and HOSP 1 expected Resident A to stay in the hospital about 7-10 days to adjust his medications. The CM stated he reviewed the changes HOSP 1 made to Resident A's medications and did not talk to Resident A's facility Psychiatrist about Resident A's condition or medications when HOSP 1 wanted to dischrage Resident A. The CM stated the Administrator (ADMIN), Director of Nursing (DON), and other facility supervisors met and decided the facility would not readmit Resident A. On June 28, 2019, at 11:50 a.m., the Director of Nursing (DON) was interviewed and stated she got a call form a nurse at HOSP 1 on June 21, 2019, that Resident A was ready to be discharged back to the facility, and the DON told the nurse the facility would not re-admit Resident A. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On June 28, 2019, at 12:25 p.m., the Admissions Clerk (AC) was interviewed and stated she was responsible for issuing bed-hold notices to residents and their families. The AC stated she called FM 1 on June 18, 2019, and spoke to him about holding a bed for Resident A at the facility, and FM 1 verbally stated he did want the facility to hold Resident A's bed. On June 28, 2019, at 1:45 p.m., the DON was further interviewed and stated Resident A's facility physician was informed on June 27, 2019, that Resident A was not coming back to the facility and did not participate in the facility's decision. On July 12, 2019, at 12:55 p.m., the DON was interviewed by telephone and stated Resident A was not at the facility, and an appeals hearing regarding the facility's refusal to readmit Resident A was held the previous week. On July 19, 2019, the ADMIN was interviewed by telephone, and stated Resident A was still at HOSP 1 and the facility planned to readmit Resident A on Monday July 22, 2019. On July 24, 2019, at 3:35 p.m., the DON was interviewed by telephone and stated Resident A was readmitted to the facility on July 22, 2019 (one month and five days after transfer to hospital). On July 19, 2019, the document titled, "...Office of Administrative Hearings and Appeals...Refusal to Readmit: (name of Resident A)...Decision and Order..." dated July 15, 2019, was reviewed and indicated, "...On June 21, 2019 (name of facility) advised (name of HOSP 1) ...that it would not re-admit (name of Resident A)...following his transfer to (HOSP 1)...On June 27, 2019, (name of FM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555309 (X3) DATE SURVEY COMPLETED 07/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNDANCE CREEK POST ACUTE 5800 W Wilson St Banning, CA 92220 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1)...requested an appeal hearing to assert Resident's right to readmission...Conclusions...Facility's actions are tantamount to an involuntary discharge...A SNF (Skilled Nursing Facility) may not use hospitalization as a mechanism to transact the permanent discharge of a resident...Facility failed to readmit Resident during his bed-hold period; and Failed to readmit Resident to the first available bed...Decision and Order...appeal is granted. (Name of facility) shall immediately readmit (Resident A) to his former bed, or if no longer available, to the next available bed..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 140O11 Facility ID: CA240000619 If continuation sheet 12 of 12